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d <br /> e <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN L.00AL HEALTH DISTRICT <br /> 1601 [. 'HAZE,.-10`j AVE., S T OCKTOtl C,: <br /> T i96 -6781 <br /> PERMIT EXPIRES 1 YEAR FROM_• DATES ISSUED <br /> !Comptett; in Triohr.a:el <br /> A ppi�eaU anLnP'�,nce v.�fnnosio�trie balSL�o;pry Uram air Ca Pi.HCAMn Oi3 rl ct so wage or7lt:n Ike 51',men r.ni p[,trnp,din[!Int!ii[iie!s ann'R iath'�`u [n5 atllnel b,mf�ne]"n <br /> 'nada an e <br /> LOW He.rnli p�suict t ._ <br /> `f v !, r 1 �- �Iv _ ,r-_�f i of Sue___..._V���-- P'•t <br /> Juh Adrpess <br /> _ ..1 if i. � phone -• <br /> Owner 5 Name a'�).w�_ •�� <br /> I f'�- �. n!.•1' r ._I�enSt:#t0. =. _^: ��Phatie <br /> tX <br /> ?Cd fess <br /> C . DESTRUCTION cL:Yar J VNELL Pr #T <br /> 'dEW WELL �_! <br /> TYPE � SYSTEM REPAIR L OTHER <br /> PUMP INSTALLATION Ci : <br /> PROP LINE <br /> SEWER LINES _�—�- DISPOSAL FLD... <br /> DISTANCE TO NEAREST. SEPTIC TA#dK OTHER WELL PITSfSUMPS <br /> FOUNDATION _ <br /> AGRICULTURE WF-L <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED ItSE TYPE OF WELL — Dia.of Well Cas+nq <br /> Op„n <br /> industrial Open Bottom Manteca Dia.at Well f.rcavauo, (_..^ Specifications Y Y <br /> ?Gravel Pack S Tracy Type OI Casing <br /> DarnestucrPtivam +' iy------- <br /> Type of Clout.,—Y� z�- <br /> -/Cl Other Delta Depth at Grout Seal I <br /> Pubhc _ <br /> Iraaauan �r�Appro.- Depth Easte7n Surface Suol Inslaued by <br /> Xtt, H P. State Work Dane — <br /> RePa't'y`�ork Done i� Type at rump <br /> lSealing Material(top 501 <br /> Well Des1lacnon Well Diameter , Filler Material toolow 501 <br /> j Depth r <br /> TYPE OF S IC WORK: NEW INSTALLATION i! REPAIRIADDITI—1 I DESTRUCTION I k avatlab a w th n 200 leer.led I public waver Is <br /> Commensal Other -- <br /> y� � Installation will sen g�{3eSidenCe <br /> Number Of living units: <br /> ---dumber of bedrooms Water table depth <br /> Character of soil to a depth of 3 feel <br /> Q �.Capacity —�� Na.Companmanis <br /> ¢C EPTEC TANK ❑ TvpelMlg Method of Disposal — <br /> J KG.TREATMENT PLr.C3 <br /> rq, <br /> Well Property Line <br /> Dissents to nearest: <br /> 10-4 <br /> + 4 Tatallengtr7ysize <br /> r ^�7 EACF{lNG LINE ❑ Na.&Length of Ines <br /> "ILTER BED ❑ Distance to nears]:: <br /> Well Foundation � Property Litre <br /> 7 - <br /> Sits Number i <br /> x <br /> a [4EEPAGE PITS (I Depth Foundation Property <br /> Z_C4 PAUMP5 LZ Distance+o nearest: h"1dl <br /> D r UDISPOSAL PONDS f7 <br /> .C] I hereby cenify that I have preparao this appucation and that the work will be done in accordance with San Joaquin county ardmancas.stars laws.and <br /> rules and regulations of the San Joaquin Local Health District. that <br /> x <br /> HOMO owner or licensed agent's signature certifies the foltowin I corlify that in the performance of the work for is h ringsubjohis� to.-co ttnstrmit is �comsat <br /> employ any person in such manner as to became subject to workman's compensation lavfs of California."Contractor's Moog or sub-co t aning signature <br /> emplcertify the persfutloon <br /> "I h rnfy that in the performance of the work for which this Permit is issuod,I shall amp oY P <br /> Tian laws of California." _ r, <br /> lice musddalE for al:r�quired inspactionr.Complete cawing on reverse side. <br /> The APP 11 ' + Date: <br /> Till <br /> Signed X ' <br /> e• a <br /> FOR DEPARTMENT USE ONLY �/3[c J• � i <br /> r tf� Date <br /> Application Accepted by ����nate <br /> Data Final Inspection by <br /> Pit or Grout Inspection by / G_ <br /> Additional CommentsL <br /> Z L 69 u rr' z')-- <br /> Additional <br /> !'}. <br /> --C}-Stk._46S&781...... ❑-Lodi 3813621 ❑Manteca 623-710 ❑Tracy 835- <br /> CA <br /> __... <br /> Applicant• Return all copses ta:Ehvironrnental Heslsh Permit/Services 1607 E+-Haie4ran Ave"P.O...Box_� 5t�^ V_ <br /> - DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED G'CAS1d RECEIVED BY INFO - <br /> t" i_,;Fn . <br /> FM l41a <br />